



































Interpreter-Mediated Therapy for Refugees:


Graduate Student Journal of Psychology          Copyright 2011 by the Department of Counseling and Clinical Psychology 

2011, Vol. 13               Teachers College, Columbia University 

52 

 

Primary Prevention of Eating Disorders in Children 

and a Proposed Parent Education Program 
 

Quinn Neugebauer 
Pepperdine University 

 

Sara Mack 
Pepperdine University 

Angel Roubin 
Pepperdine University 

 

Ashley Curiel 
Pepperdine University 

Research suggests that body dissatisfaction and concern with weight gain, characteristic of eating 

disorders, begin in childhood.  Given that eating disorders have a complex etiology, are often 

treatment resistant and result in chronic problems, prevention programs offer great appeal.  The 

attitudes underpinning eating disorders begin during childhood, yet remain somewhat malleable, 

suggesting that prevention programs initiated during elementary school offer the best possibility for 

success.  The current article reviews research on the etiology of eating disorders, general principles 

of prevention programs, and specific eating disorder prevention efforts developed thus far.  The 

article proposes a parent education program aimed at promoting healthy eating attitudes and body 

satisfaction in children to help prevent the onset of eating disorders.  The target population consists 

of the various adults involved in a young child’s life, such as parents, teachers, coaches, and 

mentors.  Children in grades 3 through 6, approximately ages 8 to 12, are a particularly important 

group to target.  The program is composed of four one-hour sessions, scheduled on four 

consecutive Saturdays, and is offered twice during the academic year.  The first three sessions 

involve parents, teachers, coaches, and mentors and are didactic and interactive in nature.  The 

fourth session includes the children, and involves an interactive puppet show.  The current article 

concludes with a critique of the program and suggestions for future research. 

 

 
 

Significance of the Problem 

 

Younger and younger children are increasingly 

concerned about their body size and eating behaviors 

(American Academy of Pediatrics, 2003).  Such concerns are 

often associated with changes in weight, a normative and 

important part of child development.  Although adolescence 

typically involves prominent bodily change, younger children 

also experience significant physical growth.  The body can 

change significantly over short periods, adding inches to 

one’s height, drastically altering one’s shape, and creating 

shifts in weight (U. S. Department of Health and Human 

Services, 2002).  Therefore, it is no wonder that some 

children endure what is commonly known as “growing 

pains.”  While the term “growing pains” typically refers to 

physical aches and pains, physical maturation can have an 

emotional impact as well, particularly in children whose 

personalities tend toward perfectionism, inflexibility, and 

constraint (Klump et al., 2004).  Constant, perhaps relentless, 

physical change requires a tolerance for uncertainty and a 

degree of adaptability in both the child and his or her family 

(Polivy & Herman, 2002).

 

                                                 
Correspondence concerning this article should be addressed to: 

Quinn Neugebauer, Clinical Psychology Program, Graduate School 

of Education and Psychology, Pepperdine University, 6100 Center 

Drive, Suite # 559, Los Angeles, CA 90045. Email: 

Quinn.Neugebauer@pepperdine.edu 

The emergence of fears around weight gain is embedded 

within a cultural context that both glorifies the pursuit of 

thinness and venerates engagement in dieting behaviors, 

which reinforces body dissatisfaction (Szmukler & Patton, 

1995).  A focus on thinness, coupled with low self-esteem 

and negative parental attitudes toward weight, presents as 

considerable risk factors for the development of a variety of 

eating disorder symptoms (Stice, Agras, & Hammer, 1999).  

While the prevalence of clinically significant eating disorders 

among children under the age of 11 does not appear to be 

increasing (Fisher, 2009), studies indicate the underpinnings 

of such disorders in pre-adolescence (Stein & Woolley, 

1996).  Adolescents who later present with clinically 

diagnosed eating disorders show signs and symptoms as 

young children (Bulik, 2002).  Therefore, effective methods 

to prevent the development of risk factors for these disorders 

are of critical importance. 

This article reviews the etiology of eating disorders, 

general principles of prevention programs, and eating 

disorder prevention efforts developed thus far.  Following 

this overview, the article proposes a parent education 

program aimed at promoting healthy eating attitudes and 

body satisfaction in children to help prevent the onset of 

eating disorders.  The program is described in terms of 

approach, target population, preparation, structure, content, 

and assessment of outcomes.  Finally, a critique of the 

program is provided.  

 



NEUGEBAUER, MACK, ROUBIN, & CURIEL 

 

53 

 

Overview of Eating Disorders  

While a poor relationship with food, hunger, and the 

body may have various presentations (e.g., reliance on fad 

diets, emotional eating, etc.), the Diagnostic and Statistical 

Manual of Mental Disorders, Fourth Edition, Text Revision 

(APA, 2000) recognizes three specific eating disorders: 

Anorexia Nervosa (AN), refusal to keep a minimally normal 

body weight; Bulimia Nervosa (BN), binge eating and 

inappropriate compensatory methods to avoid weight gain; 

and Eating Disorder Not Otherwise Specified (EDNOS), a 

clinically significant eating disorder that does not meet 

criteria for AN or BN.  Each of these disorders is 

characterized by a distorted perception of body weight and 

shape, which commonly involves issues of body 

dissatisfaction and low self-esteem. 

Nearly all cases of eating disorders are complex 

(Fairburn, Cooper, & Waller, 2008), and are often difficult to 

treat (Fairburn, 2008).  In a review of outcome studies 

involving 5,590 patients with Anorexia Nervosa (AN), nearly 

one-half of patients demonstrated a full recovery, one-third 

improved but still had symptoms, and 20% remained 

chronically ill (Steinhausen, 2002).  Furthermore, the 

mortality rate for AN is higher than for any other mental 

illness due to the common medical issues associated with 

significant loss of body weight and other AN symptoms 

(Sullivan, 1995).  Indeed, prevention of eating disorders is 

critical, as they are often associated with and contribute to 

serious medical, social, and psychological problems 

(American Psychiatric Association [APA], 2000).   

 

Etiology of Eating Disorders in Children and Adolescents 

The etiology of eating disorders is multifaceted, 

complex, and in many ways remains quite unclear (Watkins 

& Lask, 2002).  Researchers currently conceptualize the 

development of eating disorders according to 

multidimensional models that relate genetic, biological, 

psychological, socio-cultural, and familial factors   to 

particular symptoms (Jacobi, Hayward, de Zwaan, Kraemer, 

& Agras, 2004).  For the purposes of this article, 

psychological, socio-cultural, and familial factors will be 

discussed in relation to the development of eating disorder 

symptoms in children.  

Many young females value the cultural ideal of thinness, 

at times leading them to question their own bodies and 

consequently become displeased with their weight, body 

shape, and self perception (Levine & Smolak, 2006).  

Unrealistic ideals related to beauty and thinness are presented 

and reinforced by various media sources that are readily 

available to many children from diverse backgrounds 

(Herbozo, Tantleff-Dunn, Gokee-Larose, & Thompson, 

2004).  These negative images likely initiate a child’s 

decision to diet or engage in forms of weight management 

(Levine & Smolak, 2006).  Of note, repeated dieting and the 

associated weight fluctuations have been found to be a risk 

factor for eating disorders (Rohwer & Massey-Stokes, 2001).  

Although eating disorders typically emerge in 

adolescence (APA, 2000), many children in grades 3 through 

5 already exhibit body dissatisfaction; nearly 35% of children 

perceive that they “should” diet as early as the third grade 

(Pierce & Wardle, 1997).  Thus, these concerns about body 

weight and shape are present before the onset of adolescent 

development, which typically begins around age 11 and 

includes the additional development of secondary sex 

characteristics (Rohwer & Massey-Stokes, 2001). 

The transition from childhood to adolescence entails a 

reorganization of personality, cognitive, and relational 

structures as well as alterations in cultural expectations and 

social roles (Rohwer & Massey-Stokes, 2001).  When eating 

is linked to perceptions of attractiveness, control, success, 

and self-worth, it can become disordered during this 

transition (Rohwer & Massey-Stokes, 2001).  Yet, research 

indicates that despite the presence of body dissatisfaction and 

fear of gaining weight in elementary school children, these 

attitudes and behaviors are not as developed and entrenched 

as they are in their adolescent counterparts (Smolak & 

Levine, as cited by Rohwer, 2001).  Therefore, prevention 

programs that target this younger population could help 

reduce the likelihood of future eating disorder 

symptomatology during adolescence (Rohwer, 2001).  

Although eating disorders have been associated with 

upper-class Caucasian females from industrialized Western 

nations, recent research demonstrates that this pathology is 

increasingly common among minority ethnic groups in the 

United States (Woo & Keatinge, 2008).  Further, Tomiyama 

and Mann (2008) found that children who grew up in cultures 

that foster independence and separation from the family were 

often at a higher risk of eating disorders when their particular 

families did not encourage that same individuation.  These 

familial and societal factors are important to consider as they 

might impact the success of a prevention intervention. 

 

Prevention of Eating Disorders in Children and 

Adolescents 

Effective prevention programs share some principles in 

terms of program characteristics, target population, and 

implementation and evaluation (Nation et al., 2003).  

Effective programs are characterized as being 

comprehensive, having a basis in theory, using various 

teaching methods, and offering opportunities to build strong, 

positive relationships.  They are timed appropriately, are 

socio-culturally relevant to their target populations, have 

well-trained staff and include outcome evaluation (Nation et 

al., 2003).  Theory-based interventions grounded in research 

are important for prevention programs (Nation et al., 2003).  

Etiological theories address the causes (risk and protective 

factors), and intervention theories address the optimal means 

for modifying the risks.  Intervention theories form the basis 

for successful prevention programs and have been shown to 

bring about the desired changes in the causes and then the 

behavior associated with a given disorder (Nation et al., 

2003).   

Prevention programs should focus on strengthening 

protective factors, including social skills and healthy self-

perception, which function as a means of building resiliency.  



PRIMARY PREVENTION OF EATING DISORDERS IN CHILDREN 

 

54 

 

This contrasts with a focus on risk factors, such as social 

stresses, cultural influences, family dysfunction, and general 

environmental influences (Pransky, as cited by Massey-

Stokes, 2001). A focus on protective factors could include the 

implementation of skill-building strategies that help children 

develop problem-solving/decision-making skills, improve 

their abilities to evaluate social messages, and increase self-

awareness and feelings of self-worth (Rohwer, 2001).  

 

Primary Prevention of Eating Disorders 

Research on prevention is critical due to the high cost 

and challenges associated with the treatment of eating 

disorders (Loth, Neumark-Sztainer, & Croll, 2008).  

Prevention programs for eating disorders were initially 

developed to provide information and later incorporated 

socio-cultural considerations.  More recently, prevention has 

shifted to targeting groups of at-risk individuals (Stice & 

Shaw, 2004).  

Literature on the primary prevention of eating disorders 

suggests a focus on altering behaviors that impact eating 

habits, coping skills, body image, and self-esteem (Rohwer, 

2001). More specifically, Rohwer (2001) identified the 

following topics as central to a successful prevention 

program in children: pubertal changes in the body, nutrition 

and the connection between food and emotions, physical 

health and exercise, weight control and dieting, societal 

pressures to be thin, gender imbalances, personal identity, 

coping skills, and eating disorders in general.  

Because there is concern that educating the public about 

eating disorders may actually encourage them (e.g., by 

providing ideas on dieting methods), prevention should be 

geared toward building a positive body image and accepting 

the bodily changes that occur during puberty (Rohwer, 2001).  

This proposition is in alignment with the general principal 

that primary prevention consists of decreasing risk factors 

that influence a problem as well as developing qualities and 

building conditions that promote wellness (Stice & Shaw, 

2004).  

In terms of effectiveness, there have been few controlled 

studies of successful eating disorder prevention programs 

(Russell-Mayhew, Arthur, & Ewashen, 2007).  Nonetheless, 

the most effective eating disorder prevention programs have 

included cognitive interventions to modify maladaptive 

attitudes such as body dissatisfaction and behavioral 

interventions to alter dysfunctional behaviors such as fasting 

(Stice & Shaw, 2004).  In addition, they have utilized 

interactive approaches that include creating self-esteem 

strategies and developing social and relational practices that 

incorporate family and teachers.  These approaches work to 

create an environment that facilitates students' positive view 

of their bodies (Piran, 1997), an approach that has informed 

wellness-based prevention programs (Russell-Mayhew et al., 

2007).  

Furthermore, the results of one study on the 

effectiveness of a wellness-based eating disorder prevention 

program (Russell-Mayhew et al., 2007) suggested that 

involving parents and teachers was more effective in altering 

attitudes (e.g., self-concept) and behaviors of elementary 

school students than involving the students alone.  Indeed, 

parental participation in prevention is essential for a number 

of reasons (Smolak & Levine, as cited by Massey-Stokes, 

2001).  First, findings support a potential connection between 

mothers’ attitudes and behaviors and daughters’ dieting and 

eating behaviors.  Second, family members’ teasing appears 

to influence adolescent eating attitudes; teasing is believed to 

contribute to AN in prepubertal youth.  Third, parents have 

more control over younger children’s eating behaviors.  

Thus, parents might inadvertently encourage their children’s 

dieting, particularly if the parents have their own weight and 

body image issues (Massey-Stokes, 2001).  

 

The Proposed Program 

 

Russell-Mayhew and colleagues (2007) developed the 

principle model for the prevention of eating disorders in 

children.  Their model is a wellness-based prevention method 

used to target prevention of eating disorders among 

elementary and middle school students (grades 4 through 9).  

The model includes one 90-minute session with parents and 

one 60-minute session with teachers in addition to a single 

session with the students.  The model's specific application to 

a younger, elementary-school-aged population provides the 

theoretical basis of the current proposed program.  However, 

the current program expands on the single session 

parent/teacher model, providing four adult sessions to 

encourage practice between sessions, interaction with the 

material, and opportunities to ask questions and problem-

solve.  Such an approach fulfills the requirement of sufficient 

dosage that is suggestive of a successful prevention program 

(Nation et al., 2003) and is considered more conducive to 

learning and knowledge acquisition (Ethridge & Branscomb, 

2009; Stice & Shaw, 2004).  The current program also 

incorporates recommendations for families that emerged 

from Loth, Neumark-Sztainer, and Croll (2009), a qualitative 

study that assessed the impact of family environment on the 

development of eating disorder symptomatology.  In the 

study, participants in treatment for eating disorders identified 

the following areas that might have possibly prevented the 

development of their illness: increased parent support, less 

talk about weight and body shape, the promotion of healthy 

eating and exercise, increased self-esteem unrelated to 

physicality, the development of emotional regulation and 

healthy coping skills, increased awareness of eating disorder 

symptoms, and parents’ use of support. 

 

Approach 

Given the complex etiology of eating disorders, some 

experts have proposed an ecological approach to prevention.  

Such an approach considers the environmental (e.g., 

personal, group, community, etc.) and socio-cultural factors 

that may influence whether or not an individual develops a 

disorder (Levine & Smolak, 2006).  The ecological approach 

is particularly helpful in understanding the development of 

eating disorder symptomatology.  From this perspective, 



NEUGEBAUER, MACK, ROUBIN, & CURIEL 

 

55 

 

eating disorders are believed to serve as coping mechanisms 

to aid individuals in functioning within their greater social 

environment (Levine & Smolak, 2006).  The ecological 

approach is consistent with the hypothesis that cultural values 

are primarily communicated through the family (Rohwer & 

Massey-Stokes, 2001).  Therefore, the proposed program 

targets the people in the child's environment.   

The proposed program is considered a selective 

prevention program, a type of primary prevention as defined 

by the Institute of Medicine (IOM; Munoz, Mrazek, & 

Haggerty, 1996), due to its focus on parents, teachers, and 

mentors of children who may not be symptomatic but are at 

heightened risk due to a variety of cultural factors (Levine & 

Smolak, 2006).  Prevention is accomplished by educating 

participants about normative physical growth in children, 

healthy eating, and the potential impact of their own attitudes 

about weight on children’s self-image.  The underlying 

assumption is that knowledge of such topics will better guide 

the adults' future interactions with the children under their 

care (Lancy & Grove, 2010).  The following is a description 

of aspects of the proposed program, including basics of its 

development and implementation. 

 

Target Population 

The target population for the proposed program consists 

of various adults involved in a young child’s life, who might 

include an elementary student’s parents, teachers, and/or 

mentors. While the intervention is aimed at preventing eating 

disorders in children, it is initially implemented via the adults 

involved in the child’s life due to the aforementioned 

research that indicates parental and adult involvement is 

critical in preventive efforts.  

Engagement in the proposed program is particularly 

relevant for parents with children in grades 3 through 6, 

approximately ages 8 to 12, as research has shown that many 

children in this age group already hold maladaptive beliefs 

about body weight and shape (Massey-Stokes, 2001). 

Additional findings also support focusing efforts on this age 

group.  For example, females as young as six have been 

found to internalize cultural expectations of the thin ideal, 

and females as young as nine have been found to engage in 

dieting and exercise behaviors solely for the purpose of 

weight loss (Thelen, Powell, Lawrence, & Kuhnert, 1992).  

Further, significant biological changes can also occur during 

pre-adolescence, making this age group of particular concern 

for the development of eating disorder symptomatology 

(Smolak & Levine, 1996). 

 

Preparation 

The proposed program begins with one person who acts 

as the program “advisor.”  His or her primary role is to 

coordinate the administrator training, schedule dates and 

locations for the programs, and generally serve as a primary 

resource for program development.  

First, the advisor gathers preliminary data (e.g., interest 

in the program, available resources) about a community to 

which the program is to be offered.  Approximately three 

months prior to the program start date, the program advisor 

meets with several elementary school principals and 

counselors to gather information about student demographics.  

The program advisor also consults with the school’s Parent 

Teacher Association (PTA) or other parent groups that are 

actively involved in school activities.  Additional outreach 

includes visitation to the local YMCA, community sports 

leagues, and other popular organizations among the 

community’s youth.  Specific places of focus include dance 

studios, gymnastics gymnasiums, and performing arts 

centers, as these activities tend to be more highly related to 

the development of eating disorder symptoms (Massey-

Stokes, 2001).   

After preliminary research is complete, the program 

advisor seeks the availability of local psychologists, social 

workers, or other mental health professionals who are able 

and willing to participate without compensation.  These 

“administrators” are then familiarized with the program and 

its objectives and are trained in the application of its 

techniques.  

The program advisor then takes steps to market the 

program to the target community. Flyers and other 

advertising materials are distributed to the schools and 

facilities previously visited by the program advisor.  Flyers 

are posted on elementary school bulletin boards and mailed 

to each family’s home, along with a cover letter from the 

principal and school nurse advocating for participation in the 

prevention program.  Coaches, mentors, and teachers from 

these locations are invited to attend the workshops as well, as 

they also influence children’s perceptions of body image and 

health.   

To accommodate those who require childcare in order to 

attend, older student volunteers are available to provide 

childcare while parents attend program activities. The 

additional incentive of free childcare also serves to increase 

the likelihood of attendance. The program itself takes place 

in a gymnasium at a select number of elementary schools in 

the community, or other locations that are familiar and easily 

accessible. 

 

Structure 

The program is composed of four one-hour sessions, 

scheduled on four consecutive Saturdays during the academic 

year.  In addition, the program is offered twice during the 

academic year (e.g., in October and April) to reach as large 

an audience as possible and promote participant reflection 

and internalization of information.  Finally, free breakfast 

items and refreshments are offered for thirty minutes prior to 

the workshop. 

The first three sessions (each one hour in length) are 

structured to address parents, teachers, coaches, and mentors.  

The fourth session, described in further detail below, includes 

the children in the activities. The program is first offered in 

the fall, which provides time for the program advisor to make 

arrangements before long-term school, sports, and activities 

schedules are established. Another installment of the program 

is provided in the spring for those adults who were unable to 



PRIMARY PREVENTION OF EATING DISORDERS IN CHILDREN 

 

56 

 

attend the fall program or for those who wish to gain 

additional knowledge, experience, or support.  

 

Content 

The content of the first three sessions emphasizes the 

collaborative necessity of successful prevention of eating 

disorders in children (Graber & Brooks-Gunn, 1996).  These 

sessions are both didactic and interactive in nature, as such an 

integrative approach is considered more conducive to 

learning and knowledge acquisition (Stice & Shaw, 2004).  

These sessions also include psychoeducation, presented 

through open dialogue, activities, and role-play.  

Specifically, participants are taught the power of 

modeling and their influence on the younger generation 

(Graber & Brooks-Gunn, 1996).  These sessions encourage 

open discussion of parental/participant experiences that 

might have affected their own learning.  Such an approach 

may be helpful in addressing societal pressures to be thin 

(Harrison & Hefner, 2008). Participants are encouraged to 

examine the messages they could be inadvertently 

communicating to children and to identify ways to alter their 

behavior to promote a child’s health (Levine, 1987). 

The participants are encouraged to take steps toward 

altering their behaviors and monitoring the potential effects 

of these changes.  They are also taught specific skills and 

strategies, such as relaxation, which has been shown to 

prevent eating disturbances (Deckro et al., 2002).  Since both 

direct experience and reflection on that experience is 

necessary to reinforce learning (Ethridge & Branscomb, 

2009), the adults are encouraged to attempt implementation 

of the new techniques between sessions and report back with 

their experiences.  Adults who participate are given resources 

and referrals should further intervention be needed (Levine, 

1987). 

The fourth and final session of the proposed program is 

an interactive puppet show initially introduced by the Eating 

Disorders Awareness and Prevention (EDAP) organization 

for classroom instruction.  Based on the Russell-Mayhew et 

al. (2007) model, it emphasizes acceptance of diverse body 

shapes and rejection of the “perfect” body ideal.  The 

proposed program differs in that it invites the participants to 

perform in the show, even creating their own scripts and 

practicing the use of healthy dialogue.  The show is 

performed for the children during the last session.  After the 

show, the participants have the opportunity to engage in a 

guided discussion about the performance with the children 

and engage in more direct conversation about their beliefs. 

 

Assessment of Outcomes 

The outcome of the program is assessed based on the use 

of the Piers-Harris Children's Self-Concept Scale (PHCSCS) 

and the children's version of the Eating Attitudes Test 

(ChEAT). The PHCSCS, a self-report questionnaire 

developed by Piers (1999), was utilized by Russell-Mayhew 

and colleagues (2007) to measure self-concept in children 

and adolescents, and includes several subscales, such as 

Physical Appearance and Attributes and Happiness and 

Satisfaction.  The ChEAT (Maloney, McGuire, & Daniels, 

1988), is a self-report measure of children’s eating attitudes, 

food preoccupation, and dieting behaviors.  The children are 

administered the measures before the beginning of the first 

session and then again after the puppet show during the 

fourth session.  Significant changes on these measures will 

suggest correlation between the program implementation and 

the children’s risk of eating disorder development.  

The adults are also administered the children’s versions 

of the measures and are asked to complete the measures 

based upon how they believe their children might respond.  

These scores are used solely for the purpose of evaluating the 

correlation between the adults' beliefs and their children's 

responses.  It is hoped that any variance in scores will 

encourage parents to evaluate their own assumptions about 

their children’s beliefs and the effectiveness of their 

communication with their children.  Teachers, coaches, and 

mentors who do not have their own children in the program 

may choose to complete the evaluation to be compared with 

responses from a child they believe they know well. 

The effectiveness of the program is also assessed via 

pre- and post-test questionnaires, which are provided to the 

adults only.  These questionnaires serve to assess their 

knowledge of eating disorder prevention, appropriate 

behaviors to model for children, and how to promote positive 

coping skills.  It is hypothesized that the scores on these 

program-specific assessments (created by the trainers to 

assess the content learned during the sessions) will increase 

at the completion of the program.  Adults are provided a 

qualitative feedback form in which they can anonymously 

report what was most helpful in their application of the 

techniques acquired. Additionally, they are encouraged to 

provide feedback on their level of satisfaction with the 

program, including whether they enjoyed the course, would 

attend again, and would recommend it to others.  

One of the major benefits of the proposed program is the 

potential for generalization.  For example, Tolan and Guerra 

(1994) found clinic-based interventions to be limited in their 

ability to generalize improvements across settings and to 

effect lasting change once reinforcement contingencies are 

discontinued.  Conversely, community-based interventions 

produce sustained change and greater generalization because 

such efforts are anchored in one's daily life (Tolan & Guerra, 

1994).  

 

Critique of the Proposed Program 

 

Strengths of the Program 

The proposed parent education program to help prevent 

eating disorders presents a number of strengths.  First, the 

program targets parents of children who are at the optimal 

age for eating disorder prevention.  Russell-Mayhew and 

colleagues (2007) found that elementary school children and 

their parents and teachers demonstrated the most unhealthy 

and negative attitudes and behaviors toward weight and 

eating, compared to the group composed only of junior high 

students.  This finding presents an opportunity for 



NEUGEBAUER, MACK, ROUBIN, & CURIEL 

 

57 

 

preventative intervention.  Additionally, these unhealthy 

attitudes and behaviors are less ingrained in elementary 

school children, suggesting that primary prevention might be 

most effective when it includes young children, their parents, 

their teachers, and/or other adults involved in their lives 

(Smolak & Levine, 1994).  Further, many experts agree that 

elementary and middle school/junior high school students are 

the most appropriate age groups for primary and secondary 

prevention efforts (Rohwer, 2001).  In fact, one of the only 

eating disorder prevention programs found to be empirically 

supported included elementary school children and their 

parents and teachers, an approach that researchers found 

particularly effective and indicative of the need to start 

prevention programs early (Russell-Mayhew et al., 2007).  

The primary prevention design is considered the most 

effective approach to confront eating disorders as its timing 

addresses problems before they begin.  Given the complex 

nature of eating disorders and the subsequent treatment 

challenges (Fairburn, 2008), timing is of utmost importance. 

Second, the prevention program presented primarily 

targets the parents of elementary school children and 

welcomes the participation of teachers and coaches.  

Prevention models that include parents and teachers are 

believed to be more effective (Russell-Mayhew et al., 2007), 

as adults greatly influence children's attitudes toward weight 

and body image (Massey-Stokes, 2001).  Research has 

demonstrated an association between mothers’ attitudes and 

behaviors and their daughters' eating and dieting behaviors as 

well as adolescent eating attitudes and family members’ 

teasing, suggesting that parent involvement in prevention 

efforts is critical (Smolak & Levine, 1994).  Moreover, 

parents control the foods that are available at home for their 

children. Overall, focusing on parental and teacher 

involvement as part of a school-based intervention program 

has shown promise in preventing eating disorders in children 

(Russell-Mayhew et al., 2007). 

Third, consistent with the findings of Russell-Mayhew 

and colleagues (2007), the program is based at the children's 

school.  Rohwer (2001) strongly recommends schools as the 

site of prevention programs as there are sizeable audiences at 

one setting, and schools can serve as a location for early 

identification of eating disorders.  

Fourth, the multisession approach used in the proposed 

program is consistent with recommendations for sufficient 

dosage in prevention programs (Nation et al., 2003) and is 

the primary improvement over the Russell-Mayhew et al. 

(2007) model, which utilizes a single-session approach.  

Because both direct experience and reflection on that 

experience is necessary to reinforce learning (Ethridge & 

Branscomb, 2009), the current multisession prevention 

program offers a possible advantage over the Russell-

Mayhew et al. (2007) model by promoting participant 

reflection and internalization of information.  

 

Weaknesses of the Program 

As with any model, the current prevention program is 

not without limitations.  Perhaps the most salient limitation is 

the focus on parents and adults in children's lives rather than 

an emphasis on direct contact with the children.  Although 

the children participate in the fourth session of the program 

alongside the parents, one session of direct contact might not 

be sufficient.  Additional research is necessary to determine 

if the proposed program might be implemented in 

combination with another program focused on working 

directly with the children. 

A second limitation of the current program proposal is 

its limited focus on follow-up assessments.  It is possible that 

administration of the measures immediately following the 

puppet show may create a recency effect.  Long-term 

assessment is crucial to determine if the prevention program 

resulted in sustained change in attitudes and behaviors.  

Another limitation is that the program depends  upon 

voluntary parent participation. While researchers believe that 

parents are inherently motivated to participate in programs 

that might benefit their children (Levine & Smolak, 2006), it 

is possible that parents might perceive the program as a 

critical commentary on their parenting skills and decide not 

to participate.  Those parents who are in the most need of 

help (e.g., those whose children are already demonstrating 

negative eating attitudes or behaviors) might be especially 

sensitive to perceived criticism and therefore choose not to 

attend, thereby limiting the program's ability to reach all 

children in need of preventive education.  Should such a 

scenario present itself, more research on how to potentially 

make the prevention program mandatory might warrant 

further exploration. 

Even if parents attend the program, there is the risk that 

the information obtained might not be put into practice.  For 

example, parents might continue to behave in ways that 

encourage eating disordered behavior, such as dieting or 

promoting the thin body shape as ideal.  Such behavior will 

be difficult to monitor as the program relies heavily on 

parental self-report.  One way to compensate for these 

limitations might be to educate parents on how to encourage 

their children to advocate for themselves, such as seeking 

outside help from teachers, counselors, or other mentors if 

needed to avoid total reliance on the parents for assistance. 

Finally, finding mental health professionals to serve as 

program administrators on a voluntary basis may be difficult.  

Should such a circumstance arise, further research would be 

necessary to determine whether non-mental health care 

professionals could be trained to deliver the intervention and 

whether there are benefits in doing so.  

 

Conclusion 

 

Given the serious social, psychological and medical 

problems associated with eating disorders and the challenges 

encountered when treating them, prevention programs offer a 

needed approach and deserve further consideration and 

examination.  The few studies which have investigated the 

effectiveness of prevention programs  addressing eating 

disorders found that including younger children (e.g., those 

ages 8 to 12) was particularly beneficial (Russell-Mayhew et 



PRIMARY PREVENTION OF EATING DISORDERS IN CHILDREN 

 

58 

 

al., 2007).  Nonetheless, the Russell-Mayhew et al. (2007) 

model does not appear to offer the recommended sufficient 

dosage for prevention programs (Nation et al., 2003).  The 

single session format does not allow time for participants to 

interact with the material at home and return to ask questions 

or problem-solve; such interaction is critical in the learning 

process (Ethridge & Branscomb, 2009; Stice & Shaw, 2004).  

The proposed program addresses these concerns by offering 

four sessions that are interactive in nature and promote 

practice between sessions.  Moreover, this proposed program, 

while general in nature, could be modified for delivery to 

culturally diverse communities.  Ultimately, it is hoped that 

this approach will foster young children’s healthy attitudes 

toward eating and body satisfaction and will provide adults 

with adequate knowledge and tools to build protective factors 

to prevent the development of eating disorders. 

 

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